Remote RN/LPN Claims Auditor – Fraud & Compliance

WPS Health Solutions; Detroit (MI); Remote; USD 25,000 - 35,000; Full time

Benefits offered by this job

Remote work options available

Performance bonus and/or merit raise

401(k) match

Job summary

WPS Health Solutions, a not-for-profit health insurer and DoD contractor, seeks a Claims Examiner III LPN to safeguard MVH program integrity. The role blends nursing expertise with data analysis to assess medical necessity, detect unusual utilization, and ensure compliant benefits administration. Remote work options are available with state approvals.

The position requires U.S. citizenship, RN or LPN licensure, and 3+ years of clinical practice.

Qualifications

• Minimum qualifications include U.S. citizenship and RN or LPN licensure.
• 3+ years of clinical practice experience.
• Ability to learn MVH regulations, policies, and procedures.
• Ability to analyze and document medical findings.

Responsibilities

• Analyze data from anti-fraud software, claims histories, and medical records to identify potential fraud and aberrant utilization.
• Develop and manage investigative cases, review claims histories, and research allegations of fraud and abuse within MVH.
• Perform pre-payment and post-payment reviews of claims and medical records to determine medical necessity and policy compliance.
• Compile data and prepare formats ready for physician/peer review and audit summaries.
• Communicate findings clearly to stakeholders and coordinate with external partners as needed.

Skills

Clinical experience

Data analysis

Documentation

Communication skills

Regulatory understanding

Education

RN licensure (RN)

LPN licensure (LPN)

Tools

MS Excel

Job description

WPS Health Solutions, a not-for-profit health insurer and DoD contractor, seeks a Claims Examiner III LPN to safeguard MVH program integrity. The role blends nursing expertise with data analysis to assess medical necessity, detect unusual utilization, and ensure compliant benefits administration. Remote work options are available with state approvals.

The position requires U.S. citizenship, RN or LPN licensure, and 3+ years of clinical practice.